(d) The uniform prior authorization forms shall be completed as follows:

1. (1) Section A shall be pre-populated pursuant to paragraph (c) above, with the following information:

   1. a. Insurer or Pharmacy Benefits Manager (PBM) Name – company to which the form shall be submitted;
   2. b. Phone # – phone number for contacting the company regarding prior authorization;
   3. c. Fax # – secure fax number for submitting the request; and
   4. d. Electronic Prior Authorization Webpage – webpage for submitting prior authorization requests electronically, as applicable;

2. (2) Section B shall be completed by the prescribing provider to indicate the type of request being made by checking the appropriate box(es) to indicate:

   1. a. Whether the request is being made for the first time or is a request for continuation or renewal of an existing prior authorization; and

   2. b. Whether expedited review is being requested and, if so, the treating provider shall initial to make the following attestation:

      “By initialing here, I, as the treating provider, attest to the fact that this request meets the URAC (Utilization Review Accreditation Commission) health accreditation standards for urgent care in that adherence to the standard timelines: a) could seriously jeopardize the life or health of the patient or the ability of the patient to regain maximum function; or b) would subject the patient to severe pain that cannot be adequately managed without the treatment being requested”;

3. (3) Section C shall be completed by the prescribing provider to provide identifying information about the patient for whom the drug is being requested as follows:

   1. a. Patient’s Full Name – first, middle, and last name (or middle initial) of patient

      and any suffix;

   2. b. DOB – patient’s month, day, and year of birth;
   3. c. Member ID # - patient’s insurer or PBM member identification number as displayed on the patient’s insurance card; and
   4. d. Group # - patient’s insurer or PBM group number as displayed on the patient’s insurance card;

4. (4) Section D shall be completed by the prescribing provider to provide identifying and contact information for the prescribing provider as follows:

   1. a. Prescribing Provider – name of the provider prescribing the medication being requested;
   2. b. Phone # – phone number for contacting the prescribing provider regarding the prior authorization request;
   3. c. Address – mailing address for sending prior authorization determinations to the prescribing provider;
   4. d. Secure Fax # – secure fax number for sending prior authorization determinations to the prescribing provider;
   5. e. Specialty – the prescribing provider’s specialty (if multiple, include the specialty relevant to the request);
   6. f. Prescribing Provider NPI # - the prescribing provider’s National Provider Identifier number;
   7. g. Prescribing Provider DEA # - the number assigned to the prescribing provider by the U.S. Drug Enforcement Administration allowing the provider to write prescriptions for controlled substances;
   8. h. Prescriber Point of Contact (POC) Name – a person in the provider’s office (if different than the prescribing provider) that can be contacted regarding the prior authorization request;
   9. i. POC Phone # – phone number for contacting the POC regarding the prior authorization request;
   10. j. POC Secure Fax # – secure fax number for sending prior authorization determinations to the POC;
   11. k. POC Email – email address for contacting the POC regarding the prior authorization request (not required); and
   12. l. Signature / Date – form must be signed and dated by the prescribing provider or an authorized designee;

5. (5) Section E shall be completed by the prescribing provider to provide information about the patient’s diagnosis and the medication being requested as follows:

   1. a. Primary Diagnosis Related to the Medication Request – patient’s diagnosis related to which the medication is being requested;
   2. b. Medication Requested – medication name;
   3. c. Strength – medication strength being prescribed;
   4. d. Quantity – quantity of the medication being prescribed;
   5. e. Dosing Schedule – frequency of administration of medication being prescribed;
   6. f. Length of Therapy – duration prescribed for medication;
   7. g. Date of Prescription – date medication was prescribed;
   8. h. Current Treatment – indicate if this is an ongoing treatment and, if it is, the date it was started; and

   9. i. Dispense as Written (DAW) Specified – indicate if an alternate version or medication is not to be substituted for the requested medication; if yes, provide rationale for DAW by checking the appropriate box(es) as listed below and providing additional information as required:

      “1. Alternate therapies contraindicated or previously tried (please provide more information in Section F);

   10. 2. Complex patient with one or more chronic conditions (including, for example, psychiatric condition, diabetes) is stable on current drug(s); high risk of significant adverse clinical outcome with medication change (specify anticipated significant adverse clinical outcome in space below);
   11. 3. Medical need for increase in current dosage, strength and / or frequency (specify in space below: (1) dosage, strength(s) and / or frequency(s) tried; (2) medical reason);
   12. 4. Absence of appropriate formulation or indication of the drug (specify in space below); and
   13. 5. Other (specify in space below)”; and

6. (6) Section F shall be completed by the prescribing provider to provide information about the patient’s health and treatment if it is relevant to the medication being requested as follows:

   1. a. Drug Allergies - patient’s current drug allergies;
   2. b. Height - patient’s current height;
   3. c. Weight - patient’s current weight;
   4. d. Relevant Lab Values/Test Results – the name, results, and date of any laboratory or other tests that are relevant to the request;
   5. e. Previous Medications and/or Non-Pharmacologic Therapies Tried /Failed – any alternate prescription drug or non-pharmacologic therapies tried by the patient for the same purpose for which the requested medication is being prescribed, to include (as relevant) medication or therapy name; strength; dosing schedule prescribed; date prescribed/started; date stopped; and description of adverse reaction or failure;
   6. f. Contraindications to alternate therapies – the name of any alternate therapy that cannot be used because it may be harmful and description of the contraindication(s); and
   7. h. Additional information – the prescribing provider may provide any additional information to support this request.